Cordova Christian Camp (Staff) Registration 2018

If you are human, leave this field blank.

Staffer has completed 7th grade (by June 2018):
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Yes

I understand that I must pay $15 for my camp shirt:
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Yes

Staffer’s Gender:
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Male

Female

Staffer’s Last name:
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Staffer’s First name:
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Staffer’s Birth date
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Staffer’s Address:
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Staffer’s City:
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Staffer’s Zip Code:
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Staffer’s Home Phone:
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Email
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Church affiliation: (if none, type none)
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Father’s (or Guardian’s) first name:
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Father’s (or Guardian’s) last name:
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Father’s (or Guardian’s) Home Phone: (If over 18 just write 10 0’s)
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Father’s (or Guardian’s) Work or Cell Phone: (If over 18 just write 10 0’s)
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Father’s (or Guardian’s) Address:
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Father’s (or Guardian’s) City:
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Father’s (or Guardian’s) Zip Code:
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Mother’s (or Guardian’s) first name:
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Mother’s (or Guardian’s) last name:
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Mother’s (or Guardian’s) Home Phone: (If over 18 just write 10 0’s)
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Mother’s (or Guardian’s) Work or Cell Phone: (If over 18 just write 10 0’s)
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Mother’s (or Guardian’s) Address:
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Mother’s (or Guardian’s) City:
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Mother’s (or Guardian’s) Zip Code:
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Cordova Church Office

Emergency Contact #1 – first name:
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Emergency Contact #1 – last name:
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Emergency Contact #1 – Day Phone:
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Emergency Contact #1 – how related:
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Emergency Contact #2 – first name:
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Emergency Contact #2 – last name:
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Emergency Contact #2 – Day Phone:
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Emergency Contact #2 – how related:
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Staffer’s T-shirt Size:
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POLICY AGREEMENT (read 2 question)

Here are the behaviors and items that will be considered inappropriate and we will have zero tolerance for camp. Campers and staff will be sent home immediately for these infractions. *SEXUAL HARASSMENT *BULLYING *DRUGS *ALCOHOL *VIOLENCE *WEAPONS *FIGHTING It is our policy that campers and staff do not bring electronice (phones, MP3s, ipads, etc…) to camp. They will not be able to use them and Cordova Church of Christ is not responsible if they are lost or stolen. If an electronic device is discovered, it will be put in the office and the grardian can pick it up at the end of the day. If you need to get in touch with your child during the day call the church office, the phone number is 916-638-2200. If there are any questions contact the church office.
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I agree and understand the policy

I understand there will be a signature requiered on this policy by the start of camp

Medical Release

Does Staffer take medication (if yes, please explain in comment box below):
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Yes

Staffer has special dietary needs:
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Staffer is able to participate in normal physical activities (if no, please explain in comment box below):
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Yes

Staffer has asthma:
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Yes

Other special medical information or health problems:

In case of emergency, parent or guardian can be reached at the following phone #
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In case of accident or injury, I (parent or guardian) give permission for the camp director or medical staff at Cordova Christian Camp to authorize emergency treatment for the staffer.
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Yes

Staffer’s Doctor’s name:
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Staffer’s Doctor’s Phone number:
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Staffer’s Insurance Carrier:
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Staffer’s Medical Policy Number:
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I, the parent or guardian, consent to the staffer’s participation in Cordova Christian Camp. I affirm that staffer is in good health and that he/she is not under a physician’s care for any undisclosed condition that might endanger his/her health or that of other participants. I authorize in advance the medical camp staff to consent to any emergency medical or surgical diagnosis, treatment, and/or hospitalization which is deemed necessary during the camp hours for the week of camp and agree to be financially responsible for all said treatment. I also agree that the camp is not responsible for staffer before or after the hours of the camp. I understand that I will be required to pick up staffer if he/she does not abide by the camp rules. I hereby release the staff and any supporting group from any financial liability for this applicant’s participation. I have read and understand this agreement.
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Yes

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Cordova Christian Camp (Staff) Registration 2018

POLICY AGREEMENT (read 2 question)

Medical Release

Additional Comments

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This Week at Cordova 10/14 – 10/20